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UNITED STATES PUBLIC HEALTH SERVICE 



MEDICAL INSPECTION OF SCHOOLS 

A LECTURE DELIVERED AT THE SUMMER SCHOOL OF 

THE SOUTH UNIVERSITY OF TENNESSEE 

KNOXVILLE, TENN. 



J. W. SCHERESCHEWSKY 

Surgeon 
United States Public Health Service 



REPRINT No. 142 

PROM THE 

PUBLIC HEALTH REPORTS 

August 29, 1913 




WASHINGTON 

GOVERNMENT PRINTING OFFICE 

1913 



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MEDICAL INSPECTION OF SCHOOLS. 1 

A LECTURE DELIVERED AT THE SUMMER SCHOOL OF THE SOUTH UNIVERSITY OF 
TENNESSEE, KNOXVDLLE, TENN. 

By J. W. Scheeeschewsky, Surgeon, Public Health Service. 

The medical inspection of schools is one of the latest branches of 
public-health work. Still in its infancy, its early beginnings may be 
traced back to the foundations laid in school hygiene by Locke and 
Rousseau in the eighteenth century and Frank, of Austria; Ling, of 
Sweden; Lorinser, of Germany, in the nineteenth . Cohn, of Breslau, 
in 1867, was the first to call attention to the large number of eye 
defects among school children, while Bowditch, of the United States, 
was a pioneer in this country, as, by his work in measuring and 
weighing 25,000 children in the Boston schools, he contributed val- 
uable standards of the heights and weights of school children. 

It is, however, only of recent years that the whole problem of 
medical school inspection has begun to be considered in any broad 
and thoroughgoing manner. While we are still only at the begin- 
nings of this new and most important branch of public-health work 
and there is a lack of uniformity of opinion as to its scope and prac- 
tical application in various sections of this and other countries, 
nevertheless we have already gone far enough to reveal possibilities 
of great future benefits, physical, mental, and economic, accruing 
not only to the individual child, but to the entire community. 

Right of the State to Establish Medical School Inspection. 

Before proceeding to the discussion of the scope of medical school 
inspection, its ideals, and the means by which they may be realized, 
let us first examine upon what basis the enlightened citizen has a 
right to demand or the State to establish a system of medical school 
inspection. 

We are all agreed that children are the potential capital of the 
State and that it is upon the subsequent efficiency of these citizens 
in embryo that the future prosperity of any body politic depends. 

The necessity for universal education has appeared so obvious that 
the State has been freely granted the right to make this compulsory, 

1 Reprint from the Public Health Reports, Vol. XXVIII, No. 35, August 29, 1913. 

(1791) 



August 29, 1913 1792 

yet the harmful influence of physical defects and diseases, so often 
present in school children, unknown to parents and school-teachers, 
is so marked in retarding or arresting the physical, mental, and 
moral development of children that it is clearly of the utmost ad- 
vantage to the State to go a step beyond the mere prescription of 
compulsory education. 

It is evident that the usefulness of knowledge acquired in school is 
directly controlled by the ability of the pupils efficiently to embrace 
the opportunity for education and for mental equipment furnished by 
the State. Such efficiency in practice is more dependent upon the 
continuance of a state of physical well-being than upon any other 
condition. Moreover, it has been abundantly shown that physical 
defects and diseases of many kinds play a most important part in 
retarding or even arresting mental and moral development when 
allowed to extend their influence unchecked through childhood's 
years. On the other hand, it has been just as conclusively demon- 
strated that many such defects and diseases, while pernicious in their 
influence on growth and development, are, in the great majority of 
instances, either readily preventable or curable. Besides, unless such 
defects are detected by competent physical examination, their pres- 
ence is often unsuspected by teacher or parent, with the result that 
irretrievable damage may be done. 

If, therefore, we concede to the State the right to prescribe com- 
pulsory education, it follows as a necessary corollary that it is equally 
advantageous to the State so to supervise the physical condition and 
environment of its children during school life as to insure their reach- 
ing maturity with their ultimate efficiency in no way impaired by 
easily removable or preventable causes. The necessity for such super- 
vision is further emphasized when we reflect that by so doing we will 
greatly decrease the number of public charges and other dependents 
now in our midst. 

Scope of Medical Inspection of Schools. 

A good many have the impression that the object of medical 
school inspection is, primarily, to detect the presence of communi- 
cable disease among school children and to take the measures neces- 
sary to limit its spread. 

This conception of medical school inspection has arisen from the 
idea that schools form the chief agents for the spread of the commu- 
nicable diseases of childhood (measles, scarlet fever, diphtheria, and 
the like) . While unsupervised schools doubtless do furnish a means 
of assisting the spread of such diseases, they play by no means a pre- 
ponderating part in their dissemination. 

On the other hand, the type of supervision which we have just con- 
ceded as a right and duty of the State plans for a far more compre- 



1793 August 29, 1913 

hensive and thorough-going system of medical inspection, briefly, to 
maintain at all times a careful, scientific watch over the health and 
the development, mental and physical, of each individual child, pre- 
venting here, correcting there, some vice of conformation, faulty habit, 
defective physical state, and the like, so that the child, passing 
unscathed through its years of school life, arrives upon the threshold 
of citizenship with a future unhandicapped by disease, ready at once 
to become an efficient social unit. 

Any such scheme of supervision would also imply such sanitary 
inspection and control of school buildings, equipment, playgrounds, 
physical condition of employees, etc., that healthful surroundings for 
school children would be insured at all times. 

As an adjunct to this supervision, the State should also prescribe, 
as a part of the school curriculum, quite as essential as reading and 
writing, instruction in hygiene and the fundamental principles of the 
prevention of disease, so that the citizen, in future years, may protect 
the health which the State has safeguarded for him during childhood. 

Such then is the general scope of the medical inspection of schools. 
Before proceeding, however, to the discussion of the ways in which 
such supervision may be effected, we should strengthen our convic- 
tions by convincing ourselves of the need for it. The statement has 
already been made that the retarding influence of readily removable 
or preventable defects and diseases upon the physical, mental, and 
moral development of children may be profound. Let us, therefore, 
examine the extent to which such defects are present among school 
children and enumerate and briefly discuss the more important. 

Extent of Defects among School Children. 

Attention was first'called to the existence of remediable physical 
defects among school children when Cohn examined the eyes of 10,000 
scholars in the Breslau schools and found a large number of them 
suffering from defective eyesight. Kerr in England followed him 
with reports on the examination of the vision of some 50,000 chil- 
dren. Since then the results of the visual examination of a large 
number of children have been reported, with the findings that at 
least 20 per cent of school children suffer from defective vision. 

In regard to physical defects of every kind, in all places where 
such examinations have been undertaken, the percentage of children 
showing some physical defect has been extremely high. Hertel in 
1882 * reported 29 per cent of 16,000 children examined in the Danish 
schools to be unhealthy, while in 1884 Prof. Axel Key, working 
for a royal Swedish commission, reported about 35 per cent of 18,000 
Swedish pupils to be suffering from chronic physical defects. 

1 Hogarth— Medical Inspection of Schools, London, 1909, p. 16. 



August 29, 1913 1794 

In this country, out of 78,401 children examined in New York 
City in 1906, 56,259, or 71.7 per cent, presented some form of physi- 
cal defect or disease requiring treatment. 1 Out of 710 children 
examined in Minneapolis, 462, or 65.1 per cent, were defective to the 
extent of requiring medical treatment. 

It will be seen from the above that the figures reported by the 
Danish and Swedish observers are much lower than those collected in 
this country. 

The discrepancy is doubtless due, in part, to differences in opinion 
of the various observers as to what conditions should be classified 
as physical defects and partly to the fact that when Hertel and 
Key's investigations were made medical science was not nearly so 
well developed as at present and attention had not been generally 
directed to the influence upon development of diseased conditions of 
the nose and throat, such as adenoid growths. 

Be that as it may, it matters not whose results are taken, the fact 
none the less remains that wherever numbers of school children 
have been examined the percentage of physical defects has been 
found to be astonishingly high, and it is the discovery of this high 
percentage of defects which has given impetus to the movement 
for the medical inspection of schools. 

More Important Defects and Diseases Among School Children. 

It will now be pertinent to enumerate and briefly to discuss some 
of the more important types of defects and diseases from which 
school children suffer, though lack of time forbids anything but the 
merest outline. Such defects and diseases may be divided into the 
following groups for the purposes of classification. 

1. Defects or diseases affecting the senses (hearing, vision, etc.). 

2. Defects or diseases affecting the state of nutrition or devel- 
opment. 

3. Communicable diseases. 

DEFECTS OR DISEASES AFFECTING THE SENSES. 

Sight and hearing are the two senses it is the most important to 
safeguard during childhood, and yet it is those two which we find 
most commonly defective among school children. Sight and hearing 
form the chief percipient apparatus through which knowledge is 
acquired, and upon their integrity, in later years, depends a large 
part of individual efficiency. 

Many children, not learning properly in school, are backward only 
because of some defect of the eyes or ears, usually of a remediable 
nature. Moreover, unless such defects are early discovered and cor- 
rected, the efforts the child makes in overcoming his handicap may 

1 Medical Inspection of Schools, Gulick and Ayres, New York, 1908, p. 87. 



1795 August 29, 1913 

result in increasing damage. In this way a defect, originally slight, 
may become a serious bar to later efficiency. 

It has already been stated that some 20 per cent of all school 
children suffer from defective vision. 

Defective hearing. — Some 6 or 7 per cent of all school children have 
defective hearing. This defect is often due to chronic disease of the 
middle ear (running ears), a frequent result of one of the infectious 
diseases of childhood (measles, scarlet fever), or the deafness may be 
mechanical in origin and due to blocking of the opening of the ear 
into the throat (the Eustachian tube) by reason of the presence of 
adenoid growths in the nasopharynx (portion of the throat above the 
level of the soft palate, into which the nose and ears open). The 
early detection of defective hearing in children is extremely impor- 
tant, as in most instances the hearing can be greatly improved or 
made normal by appropriate treatment, while the condition, when 
neglected, may grow rapidly worse, thus permanently handicapping 
the child, or, in the case of running ears, in addition to deafness, 
abscess of the bones of the skull or the brain and its enveloping 
membranes may result. In such instances the outcome may be very 
serious. Prompt surgical treatment is required, and the condition 
may end in death. It seems hardly necessary to comment further 
on the great importance of the sense of hearing and the implied 
necessity for a careful supervision of the hearing of all school children. 

DEFECTS OR DISEASE AFFECTING THE GENERAL NUTRITION. 

While many of the communicable diseases exercise a most un- 
toward influence upon the subsequent development, such as hook- 
worm infection, or may involve one of the essential bodily senses, as 
that of vision, as in trachoma, these diseases are all due to the action 
of specific organisms and will be considered under a separate heading. 
The defects and diseases discussed in this section originate, as a rule, 
from a variety of causes, dependent, in the last analysis, on ignorance, 
poverty, or both, and their alleviation demands, first, their prompt 
recognition when present in children, and, second, missionary work 
in the homes of the affected scholars. 

Malnutrition. — The most important of these defects is malnutrition, 
and by malnutrition we mean a subnormal or a faulty growth of the 
various tissues and organs of a child's body. The term does not 
necessarily imply that the children have been underfed. 

In addition to being the result of one of the communicable diseases, 
malnutrition may depend upon any one of the following causes: 
Unhealthful environment in the home or the city ward; improper 
feeding from birth; lack of sufficient play and fresh air; under and 
over feeding; rickets; defective teeth, etc. 



August 29, 1913 1796 

Malnutrition, besides decreasing resistance to the infectious diseases, 
is provocative of undersize, stunted or arrested development, anemia, 
pallor, listlessness, mental dullness or apathy and backwardness. 

Adenoid growths . — Situated in the nasopharynx, just back of the 
openings of the nose into the throat, is a small collection of adenoid 
tissue (glandular tissue, similar in structure to that of the tonsils). 
This collection is more prominent in children than in adults, is prone 
to enlargement and frequently attains such size as to interfere 
markedly with free nose breathing. The projecting growth is also 
apt partially to block the openings of the ears into the throat, so that 
dullness of hearing is the result. The affected child becomes a 
chronic mouth breather, a condition, which, if persistent, entails many 
unfortunate consequences. 

The throat and lungs become irritated by breathing air which has 
been imperfectly filtered and moistened. This is not the case when 
the air is drawn through the nose, for the nasal passages are con- 
structed for the purpose of warming, humidifying, and removing 
dirt particles and germs from the air we breathe. 

The disuse of the nose for breathing leads to a lack of develop- 
ment of the facial bones. This in turn causes an undeveloped con- 
dition of the dental arch, causing the teeth to be overcrowded, irregu- 
lar, and poorly opposed to each other, so that defective teeth and the 
disordered nutrition they entail follow in the train. Moreover, 
mouth breathing in the place of nose breathing interferes with the 
proper development of the lungs and chest. Breathing becomes 
gasping and superficial, leading to weak respiratory muscles and a 
poorly developed thorax. This is accompanied by a lack of the 
vitality and resistance to disease which we find the natural com- 
panions of big lungs and a big heart. The disordered nutrition and 
dull hearing consequent upon adenoid growths also lead to mental 
dullness, apathy, and backwardness. Adenoid growths are readily 
removed by means of a slight operation. Their pernicious influence 
upon the mental and physical development of children is so great 
that it is imperative to detect and remove them early. 

Enlarged tonsils. — Enlargement of the tonsils usually goes hand 
in hand with adenoid growths. Intended originally to act as a 
means of protecting the body from infection gained through the 
mouth, the tonsils lose much of their protective powers when enlarged, 
and instead of serving as organs of defense form traps for catching 
harmful germs which they have lost their power to destroy. Children 
suffering from enlarged tonsils are apt to lose much time from school 
by reason of recurring sore throats, and are liable to rheumatic 
fever, diphtheria, and tuberculosis. They may serve as dissemi- 
nators of an infection, while at the same time their own development 
is most unfavorably influenced by the presence of the enlarged 
tonsils. 



1797 



August 29, 1913 



Spinal curvatures. — These are often due to vicious postures caused 
by improper desks, bad lighting, undeveloped musculature, congenital 
difference in leg length, etc. Besides distorting the figure and un- 
favorably influencing physical development by reason of the resulting 
asymmetry, the altered relations of the bones and ligaments, together 
with the faulty distribution of the body weight in the erect position, 
spinal curvatures may lead to pains and weakness of the vertebral 
joints. Moreover, the faulty relations of the bones and the joints of 
the spinal column prevent the proper development of the heart and 
lungs. 

Besides this, spinal curvatures are frequently symptoms of Pott's 
disease or tuberculosis of the spine. As the disease must be com- 
paratively far advanced before any deformity is produced, the neces- 
sity is apparent for a careful examination and determination of the 
cause in all vicious postures of children. 

Flatfoot. — Investigation has shown that an unsuspectedly large 
number of children suffer either from weak arches (probated foot) 
or flatfoot. Flatfoot is a common cause of much suffering and loss 
of bodily efficiency. In most instances the foundations of the dis- 
order are laid in childhood through the use of defective shoes, im- 
proper standing postures, lack of development of the foot and leg 
muscles, and lowered states of the general nutrition. In most in- 
stances the use of proper corrective measures where applied in 
childhood will overcome or arrest the defect, so it is important to 
detect commencing flatfoot in children before the changes in the re- 
lation of the bones and ligaments of the foot become permanent. 

Defective teeth.— An astonishingly large number of school children 
have defective teeth. Most of us regard teeth merely as aids to masti- 
cation and as ornaments to the mouth. Their loss or unsightliness 
seems to be regretted only from the cosmetic standpoint. In reality, 
the integrity and proper development of the teeth and dental arches 
have a most important relation to the general health and physical 
development. The permanence of the teeth in the jaws throughout 
life depends in a large measure upon the "occlusion" or the way the 
teeth fit together when the jaws are closed and the amount of avail- 
able chewing surface. 

Teeth well opposed and their chewing surfaces all available for 
use last well, and the constant use strengthens them in their sockets. 
Faulty " occlusion" or lack of ability of opposing teeth to come in 
contact with each other leads to then early decay through disease 
and fermentation of accumulated food particles. Decay started in 
such teeth readily extends to the others. 

Not only do defective teeth contribute to defective development 
and a depraved state of health by reason of malnutrition and indi- 
gestion from faulty chewing, but the presence of decayed teeth and 
8040°— 13 2 



August 29, 1913 1798 

diseased gums greatly increases the number of harmful germs in the 
mouth. The germs are swallowed with food and saliva, and the 
poisons they generate are absorbed and serve still further to lower 
the vitality. 

Certain experiments made by dentists in Cleveland, Ohio, have 
given some very encouraging results. A number of school children 
from schools in the poorer section of the city and suffering from 
defective teeth, had their mouths placed in good condition, with the 
result that a remarkable gain in weight, general health, asid scholastic 
standing ensued. 

There can be no doubt but that a small amount of attention to 
the teeth in childhood is of inestimable benefit and far outweighs the 
most expensive and skilled treatment in later years, when it is too 
late. The teeth are such important factors in a sound mental and 
physical development that they are among the most important 
points covered by medical school inspection. 

COMMUNICABLE DISEASES. 

Vaccination. — Vaccination against smallpox is the most efficient 
safeguard ever contributed to preventive medicine against what was 
one of the worst diseases. Were everyone properly protected by 
vaccination, smallpox would cease to exist. Any system of medi- 
ical inspection of schools therefore should supervise vaccination in 
school children, nor would children be allowed to attend school 
unless successfully vaccinated or shown to be one of those occasional 
individuals who are naturally immune both to smallpox and to 
vaccination. 

Infectious diseases of childhood. — These are important not only 
because the ensuing mortality is greater than is popularly supposed, 
but because they may predispose to other diseases, such as tubercu- 
losis, and several of them (e. g., measles, scarlet fever, diphtheria, 
etc.) may result in permanent disabilities. Moreover, the school- 
room is a place favorable to their spread. The necessity, therefore, 
is obvious for their detection in the school and the exclusion of chil- 
dren attacked until all danger of transmitting the disease to others 
is past. It follows from the foregoing that teachers should be familiar 
with the symptoms of the onset of these diseases. 

Tuberculosis. — The importance of tuberculosis as a cause of death 
is well known to all. Some 5 to 15 per cent of all school children 
suffer from active tuberculosis. Such children, when undetected, not 
only may serve as a source of infection to their schoolmates, but 
their continued presence in the environment ordinarily pertaining to 
schoolrooms may rob them of the chance of recovery they would 
otherwise have, for childhood is the period of life showing the greatest 
susceptibility to tuberculosis, as it is also the period holding out the 
greatest hope for recovery under intelligent treatment. 



1799 August 29, 1913 

Intestinal parasites. — The investigations of recent years have shown 
the great importance of the presence of intestinal parasites in school 
children. Hookworm, which infects a large number of children in 
the southern States, is well known for the depraved condition of the 
health, anemia, stunted growth, mental apathy, and backwardness 
which it produces. Hookworm infection is undoubtedly the greatest 
single foe to advances in material prosperity in those States in which 
it is prevalent. It is not, however, a matter of general knowledge 
that other intestinal parasites, such as the whipworm (Trichoceplialus 
dispar), the dwarf tapeworm, or even the ordinary roundworm, are 
capable of producing a high grade of anemia and otherwise inter- 
fering with the proper physical and mental development. 

Intestinal parasites, as a rule, can be readily expelled by simple 
treatment. Their continued presence in the alimentary tract is so 
apt to be followed by unfortunate results that the examination of 
school children for intestinal parasites is indicated as a routine 
measure in districts where they are prevalent and constitutes an 
important part of medical school inspection in such regions. It 
should not be forgotten that children infected with intestinal para- 
sites, even if the infection is so light as not to cause general symp- 
toms, are, nevertheless, constantly passing the eggs in their excreta, 
and hence may serve as disseminators of the infection. This is 
particularly true in those sections where the insanitary privy is the 
rule rather than the exception. 

Chronic communicable diseases. — In this category are included cer- 
tain skin diseases usually affecting the scalp, such as ringworm and 
favus, and trachoma, a chronic contagious disease of the eyelids. 
Favus and ringworm are regarded as ' 'loathsome contagious diseases, " 
while trachoma is designated as a "dangerous contagious disease" 
by the Federal authorities when found in immigrants. The exclu- 
sion of immigrants so affected is mandatory by law. Trachoma is 
readily spread by the close personal contacts of the schoolroom and 
playground, and may result in permanent impairment of the vision 
or even in blindness. 

An accurate diagnosis of the presence of trachoma can be made 
only by turning up the eyelids of the affected individuals. In the 
absence of such inspection, some of the unfortunate results of tra- 
choma, such as ulceration of the cornea, inflammation of the cornea 
(keratitis), etc., are likely to be attributed to other causes. 

The disease is chronic, and when well established very difficult to 
cure. Hence it is of great importance to include examination for 
this disease in any form of medical school inspection. 

Vermin. — It is astonishing to find the large number of school 
children infected with vermin such as body and head lice. Besides 
indicating neglect and poor surroundings in the home, the presence 



August 29, 1913 1800 

of vermin may give rise to distressing eczema of the scalp or body. 
It has also recently been shown that the body louse is an agent for 
the transmission of typhus fever. 

Mental deficiency and nervous affections. — Besides protecting the 
bodies of school children the state of their minds and nervous sys- 
tems requires supervision from the medical standpoint. A certain 
proportion of children, either by heredity or through causes oper- 
ative in early years, are peimanent mental defectives. Others are 
apparently backward, but the underlying cause, while concealed, may 
originate in some physical defect discoverable only after competent 
examination. Epilepsy, neurasthenia, hysteria, and other nervous 
affections are not at all uncommon among school children, and 
proper attention in childhood may have the effect of turning these 
sufferers into useful citizens, rather than chronic invalids and inmates 
of institutions. 

We clearly see, therefore, the necessity for the careful examination 
of mentally abnormal and deficient school children, so that the 
exact grade of their mental or nervous defect may be determined and 
the underlying cause made clear. The natural outcome of such 
examinations would be the creation of special classes for abnormal 
children. 

Having thus briefly indicated some of the more important and 
common defects from which school children suffer and which have 
more or less pernicious influence upon their development and future 
usefulness, let us now look into the legislation provided, so far, in 
this country for dealing with the situation. 

Unfortunately, up to the present time, such legislation is by no 
means so universal or far-reaching as it ought to be. 

Twenty States, as follows, have recognized the necessity for the 
medical inspection of schools and have made some legal provision for 
its conduct: California, Colorado, Connecticut, District of Columbia, 
Indiana, Louisiana, Maine, Massachusetts, Minnesota, New Jersey, 
New York, North Dakota, Ohio, Pennsylvania, Ehode Island, Utah, 
Vermont, Virginia, Washington, and West Virginia. 

In 9 of the States the law is permissive, while in 11 it is mandatory. 
Of these 20 States, Massachusetts was the first to make medical in- 
spection of schools mandatory by law in 1906, the legislation in the 
other States being passed from 1909 to the present time. 

A considerable diversity exists in the kind of medical supervision 
contemplated, varying from examination for contagious diseases 
only to complete physical examination of pupils, teachers, and 
employees for defects of all kinds. 

Massachusetts has probably the best and most developed system 
of medical school inspection in this country. The Massachusetts law 
provides (1) for the detection of contagious diseases in schools; and 



1801 August 29, 1913 

(2) for the annual examination of children, (a) by physicians for 
noncontagious physical defects, and (&) by teachers for defects of 
eyesight and hearing. 

It is evident, however, when we study what has been done as yet 
in medical inspection of schools, that the work is not sufficiently com- 
prehensive. Too little money is appropriated, as a rule, for the pur- 
pose, and all available forces are not being generally utilized to their 
full capacity. 

Let us then discuss the groups of persons who should make up the 
medical school-inspection staff and the extent of their duties and 
responsibilities. 

These agents for the medical school inspection of children are as 
follows: (1) The school physician, (2) the school nurse, and (3) the 
teacher. 

The Teacher. 

We will begin with the teacher because her importance as an 
agent in medical school inspection has been generally overlooked. 
Hitherto teachers have been chiefly regarded as agents of instruction 
and discipline. No concern has been felt with respect to the part 
they might play in regard to the supervision of the children's health. 
Yet the teacher's position is filled with potentialities for good in 
such supervision. 

In the first place, no one is brought into such close association 
with the class members as the school-teacher, and none, by precept 
and example, can exert so lasting an influence upon their mental 
and physical evolution. The sphere of usefulness of teachers can 
therefore be greatly increased by a good working knowledge on their 
part of the laws of health, the prevention of disease, and the funda- 
mentals of school hygiene, and by being familiar with the more 
ordinary manifestations of contagious disease. 

The school-inspection laws of most States provides for tests of the 
sight and hearing of school children by teachers. These tests are 
easily learned and readily executed. Their purpose is to single out 
the pupils having defective sight and hearing, so that the true cause 
and extent of their defects can be ascertained by competent medical 
examination and the proper treatment prescribed. 

The teacher should also be the person to keep a record of the heights 
and weights of the children in the class. Recent studies have shown 
the close relation of height and weight to progress in physical and 
mental development. 

According to Prof. Bird T. Baldwin, of Swarthmore (who has not 
as yet published his observations), mental maturity depends upon 
height and weight, the tallest and heaviest children of the same age 
being mentally the most mature. 



August 29, 1913 1802 

Steady growth and increase in the body weight constitute most 
important indices to the rate of progress being made by a child. 
Hence if a child fails to gain normally something always is wrong, and 
an examination is required to discover the trouble. 

It is earnestly to be hoped that the time is near when all teachers, 
before receiving teaching certificates, will be required to possess 
training in testing eyesight, hearing, and mental deficiency besides 
being grounded in school hygiene and the recognition of the more 
usual communicable diseases. 

Nothing is more certain than that in the teacher we have an agent, 
hitherto neglected, who, if properly Utilized, is susceptible, in the 
highest degree, of improving the health of school children. This is 
especially true in the case of rural schools, where the communities are 
small, the school the usual center of culture and information, and the 
influence of the teacher extensible to the home. 

It is plain from the foregoing that we are increasing the require- 
ments and qualifications of a profession which is already loaded to 
capacity with work. If, then, as Prof. William James puts it, we 
are going to require the teacher to "energize upon a higher plane," 
the school authorities in turn must do something for the teacher. 
This "something" means that the teacher should be better paid and 
have smaller classes. The reduction in the average size of classes will 
be a most important step in advance, for it will signify that the pupil 
is no longer a mere name to the teacher, but an individual differ- 
entiated plainly in the teacher's mind from his classmates, thus insur- 
ing much closer observation and consideration of his various aptitudes 
and requirements. 

The results of the general entry of teachers as effectives in the 
army of health crusaders are certain to be of the happiest order so 
far as the community at large is concerned. 

The School Physician. 

If we increase the qualifications demanded of teachers from a 
health standpoint, what shall we say of the school physician ? In this 
country at present the school physician, usually a busy practitioner 
or a young man just starting out to conquer a place in his profession, 
is paid a small salary for the part of his time devoted to medical 
inspection of schools. Owing to the newness of public-health work 
in general he does not, as a rule, approach his duties with the proper 
viewpoint. His idea of doctoring is to treat disease, not to prevent it. 
He is deficient in consequence in that breadth of mental grasp which 
must characterize all who work in the great preventive field of 
medicine. 

The school physician should be primarily a man of wide general 
qualifications, with insight into human nature and its psychology. 



1803 . August 29, 1913 

He should be a keen observer, an acute and accurate diagnostician, 
a progressive sanitarian, especially with respect to school hygiene 
and the psychology of education. It goes without saying that he 
should be thoroughly familiar with communicable diseases and the 
necessary technic of bacteriologic and laboratory diagnosis; with all 
details of school architecture, equipment, and the like; with disin- 
fection, lighting, heating, sanitation, and, in a word, with all the 
minutiae which would increase his efficiency in this particular phase 
of professional activity. In addition to all this, he must be a patient, 
enthusiastic, forceful man, devoting all his time to this work. It is 
evident that such a man must receive and is fully worth adequate 
compensation. The money spent, however, in paying men of this 
caliber will be returned manifold in benefits to the State. 

His duties would consist in a preliminary examination of all school 
children at the beginning of the school year. The object of his 
primary examination would not be so much a complete survey of 
the child's physical condition as to establish the general physical 
status, the freedom from communicable disease of any kind, includ- 
ing communicable disease of the eyes, such as trachoma, and to 
determine the presence of satisfactory protection against smallpox 
by vaccination. 

Before the close of the school year each child in his district is to 
receive a careful physical examination, the results of which are made 
a matter of permanent and accurate record. Children found to 
have defective vision or hearing by the teacher's test are carefully 
examined by the school physician, and the exact nature and extent 
of the defect determined. 

In addition to this the doctor makes mental examination of chil- 
dren, when necessary, in order to determine the grade of any mental 
deficiency which may be present, and makes recommendations, in 
the case of such retarded pupils, as to the special classes in which 
they should be placed. 

Moreover, the school physician is not satisfied with the scope of his 
duties merely in relation to the child. He examines physically all 
teachers and school employees, thus insuring that only those free 
from communicable disease come in contact with the children. 

Besides these duties the school physician is the sanitarian of the 
school buildings and grounds. His supervision includes the architec- 
ture of school buildings, school equipment, lighting, heating, ventila- 
tion, cleaning, sewerage and water supplies, playgrounds, disinfec- 
tion, and the like. He also frames such sanitary regulations as are 
necessary in order to maintain the school and its environment con- 
stantly in a sanitary condition, and their condition is checked by fre- 
quent inspections. 



August 29, 1918 1804 

He should, moreover, instruct teachers in matters pertaining to 
school hygiene and the health of their pupils. 

It is seen from the foregoing that no easy job is outlined for the 
school physician, and it is equally evident that men who fulfill these 
qualifications will be great powers for good in any community. 

The School Nurse. 

Wherever employed school authorities have been enthusiastic in 
praise of the good accomplished by school nurses. One at least 
should be in daily attendance at each school. They attend to minor 
injuries and diseases, collect children to be examined by the school 
physician from the various classrooms, assist in keeping records, 
follow up children in their homes to ascertain the causes for absence, 
urge parents to have corrected physical defects reported in their 
children, discover what home conditions require correction in the 
case of children not progressing satisfactorily from a physical or 
mental standpoint, and the like. 

The school nurse is a most valuable agent for extending the educa- 
tional sphere of the school into the home. She has made herself 
indispensable wherever introduced. 

The School Clinic. 

The apparatus for the medical supervision of schools that has just 
been outlined will undoubtedly detect defects and diseases in pupils, 
watch over their health during school hours, and greatly improve 
the sanitation of school buildings and grounds, besides insuring a 
healthy teaching staff and school personnel. 

But of what avail is it to detect a defective or diseased condition in 
children unless the defect is remedied or the disease cured ? While 
the experience varies in different localities, even under the most 
favorable conditions, when defects in children are brought to the 
parents' attention a large percentage of such defects and diseases are 
allowed to exert their baneful influence unchecked, often leading to 
permanent physical handicaps and, in the case of such diseases as 
ringworm or trachoma, to the exclusion of children from school for 
long periods. 

Adenoid growths, enlarged tonsils, and defective teeth form another 
class of defects which parents are prone to neglect, even after atten- 
tion has been called to their existence, through ignorance of their 
effects, until the damage wrought is irretrievable. When the parents 
try to heed advice given for the correction of physical defects and are 
too poor to employ a physician for the purpose, the cry goes up that 
hospitals and dispensaries, already overcrowded beyond their capac- 
ity, have their facilities further clogged by the crowds of school chil- 
dren applying for relief. Again the time consumed in waiting their 



1805 



August 29, 1913 



turn in such crowded institutions is apt to discourage well-meaning 
parents and their children so that the defect remains uncorrected. 

The obvious answer is the establishment of clinics solely for school 
children. Such clinics are specially adapted for the treatment of 
defects and diseases peculiar to school life. The treatment afforded 
is prompt and efficient, and, wherever they have been established, 
the results have been brilliant and of lasting utility. 

The Country School. 

What of the country school ? It may well be urged that, while the 
kind of medical supervision just outlined is suited for the densely 
populated urban community, rich in funds, what can be done to fur- 
nish medical supervision in the country where the funds are scanty 
and the schools small and separated by great distances? 

Everything that applies to medical school inspection in cities ap- 
plies with even greater force in the country, and the need also is 
greater. Inspection of many of our rural schools has revealed insani- 
tary conditions in need of immediate correction. In the hookworm 
States whole schools are found infected with the disorder and, indeed, 
in this country, rural sanitation to-day is a problem presenting a vir- 
gin field. 

In answer one may suggest that the qualifications in hygiene and 
sanitation of teachers be raised as previously described, and that, 
wherever practicable, school nurses be attached to rural communities. 
The medical inspection may be performed, as is the case in England, 
by traveling medical school inspectors, employed by the State, with 
good salaries and travel allowances. The services of local physicians 
can be enlisted, provided they pass some form of State examination 
as to their special qualifications. The correction of visual and dental 
defects, together with such other conditions as require expert or 
special treatment, can be effected by means of traveling school clinics 
which visit localities where the reports of the medical school inspectors 
show their services to be needed. 

In conclusion it may be said that, in common with all new prob- 
lems, that of the medical inspection of schools needs working out 
and the future is filled with rich promises of good to be accomplished. 
The main point which we have for congratulation is that its potential- 
ities are now beginning to be fully recognized, and it remains the duty 
of all who can to extend, so far as in them lies, the field of its appli- 
cation. 



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